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Next-Generation Sequencing of CYP2C19 in Stent Thrombosis: Implications for Clopidogrel Pharmacogenomics

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Abstract

Purpose

Describe CYP2C19 sequencing results in the largest series of clopidogrel-treated cases with stent thrombosis (ST), the closest clinical phenotype to clopidogrel resistance. Evaluate the impact of CYP2C19 genetic variation detected by next-generation sequencing (NGS) with comprehensive annotation and functional studies.

Methods

Seventy ST cases on clopidogrel identified from the PLATO trial (n = 58) and Mayo Clinic biorepository (n = 12) were matched 1:1 with controls for age, race, sex, diabetes mellitus, presentation, and stent type. NGS was performed to cover the entire CYP2C19 gene. Assessment of exonic variants involved measuring in vitro protein expression levels. Intronic variants were evaluated for potential splicing motif variations.

Results

Poor metabolizers (n = 4) and rare CYP2C19*8, CYP2C19*15, and CYP2C19*11 alleles were identified only in ST cases. CYP2C19*17 heterozygote carriers were observed more frequently in cases (n = 29) than controls (n = 18). Functional studies of CYP2C19 exonic variants (n = 11) revealed 3 cases and only 1 control carrying a deleterious variant as determined by in vitro protein expression studies. Greater intronic variation unique to ST cases (n = 169) compared with controls (n = 84) was observed with predictions revealing 13 allele candidates that may lead to a potential disruption of splicing and a loss-of-function effect of CYP2C19 in ST cases.

Conclusion

NGS detected CYP2C19 poor metabolizers and paradoxically greater number of so-called rapid metabolizers in ST cases. Rare deleterious exonic variation occurs in 4%, and potentially disruptive intronic alleles occur in 16% of ST cases. Additional studies are required to evaluate the role of these variants in platelet aggregation and clopidogrel metabolism.

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Funding

This study was supported by NIH/NHLBI grant U01 HL128606 to N.L.P. PLATO study was funded by AstraZeneca.

Author information

Authors and Affiliations

  1. Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA

    Joel A. Morales-Rosado, Saurabh Baheti, Gregory D. Jenkins, Hugues Sicotte, Stephen Johnson & Eric W. Klee

  2. Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA

    Joel A. Morales-Rosado & Eric W. Klee

  3. Vanderbilt University School of Medicine, Nashville, TN, 37215, USA

    Kashish Goel

  4. Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA

    Lingxin Zhang, Liewei Wang & Richard Weinshilboum

  5. Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden

    Axel Åkerblom, Niclas Eriksson, Lars Wallentin & Stefan James

  6. Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA

    John L. Black

  7. Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK

    Robert F. Storey

  8. St. Michael’s Hospital, University of Toronto, Toronto, Canada

    Shaun G. Goodman

  9. Canadian VIGOUR Centre, University of Alberta , Edmonton, Canada

    Shaun G. Goodman

  10. Medical Genome Facility, Mayo Clinic, Rochester, MN, USA

    Bruce W. Eckloff

  11. Division of Epidemiology, Mayo Clinic, Department of Health Sciences Research, Rochester, MN, USA

    Suzette J. Bielinski

  12. Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA

    Veronique L. Roger, Charanjit S. Rihal & Naveen L. Pereira

Authors
  1. Joel A. Morales-Rosado
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  2. Kashish Goel
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  3. Lingxin Zhang
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  5. Saurabh Baheti
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  6. John L. Black
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  7. Niclas Eriksson
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  8. Lars Wallentin
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  9. Stefan James
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  10. Robert F. Storey
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  11. Shaun G. Goodman
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  12. Gregory D. Jenkins
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  14. Suzette J. Bielinski
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  15. Hugues Sicotte
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  16. Stephen Johnson
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  17. Veronique L. Roger
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  18. Liewei Wang
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  19. Richard Weinshilboum
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  20. Eric W. Klee
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  21. Charanjit S. Rihal
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  22. Naveen L. Pereira
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Corresponding author

Correspondence to Naveen L. Pereira.

Ethics declarations

The protocol was reviewed by the IRB and approval was obtained for this study.

Disclaimer

The sponsor had no role in data analysis, interpretation, or manuscript writing for this project.

Conflict of Interest

Shaun Goodman is supported by the Heart & Stroke Foundation of Ontario/University of Toronto Polo Chair and receives research grant support and speaker/consulting honoraria from AstraZeneca, Bayer, Bristol-Myers Squibb, Daiichi-Sankyo, Eli Lilly, and Sanofi. Lars Wallentin received research grants, consulting fee, lecture fee, and travel support from AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, and Pfizer; institutional research grant, consulting fee, lecture fee, travel support, and honoraria from GlaxoSmithKline; institutional research grant from Roche Diagnostics, Merck & Co; and consulting fees from Abbott. Axel Åkerblom received consulting, lecture fees, and institutional research grant from AstraZeneca. Niclas Eriksson received institutional research grant from AstraZeneca. Robert F. Storey has received research grants and personal fees from AstraZeneca, GlyCardial Diagnostics and Thromboserin, and consulting/lecture fees from Amgen, Bayer, Bristol Myers Squibb/Pfizer, Haemonetics and Portola. Richard Weinshilboum and Liewei Wang are cofounders of and stockholders in OneOme LLC, a pharmacogenomic decision support company. John L. Black and the Mayo Clinic have licensed intellectual property to AssureX Health (Myriad) and received royalties. He is also a co-founder of OneOme LLC and, with Mayo Clinic, has intellectual property to the company and owns stock in the company. The remaining 13 authors, Joel A. Morales-Rosado, Kashish Goel, Lingxin Zhang, Saurabh Baheti, Stefan James, Gregory D. Jenkins, Suzette J. Bielinski, Hugues Sicotte, Stephen Johnson, Veronique L. Roger, Eric W. Klee, Charanjit S. Rihal, and Naveen L. Pereira, do not have a conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.

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Morales-Rosado, J.A., Goel, K., Zhang, L. et al. Next-Generation Sequencing of CYP2C19 in Stent Thrombosis: Implications for Clopidogrel Pharmacogenomics. Cardiovasc Drugs Ther 35, 549–559 (2021). https://doi.org/10.1007/s10557-020-06988-w

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